Consent & Client Claiming Form for all New Clients- complete this form before your first session so we can process your Medicare Rebate or Private Health claims

Please call 4263 0518 or email clairegodsellpsychology@gmail.com

Full name of client*

FirstLast

Client's Date of Birth (eg 11/10/1978)*

Is the client under 18 years (or is there a different Medicare claimant)

No - the client is 18 years or older

Yes - the client is under 18 or there is a different Medicare claimant

Email Address*

Mobile Number (for sms appointment reminders)*

Name of Emergency Contact/Next of Kin*

FirstLast

Emergency Contact Phone Number*

How did you hear about Claire?*

GP

Psychiatrist

APS Website

A friend

An organisation

How will a REBATE be claimed for psychology sessions:*

Medicare - a Mental Health Plan will be used

Private Health Insurance

Department of Veterans Affairs (DVA) are paying for these sessions

Vietnam Veterans Counselling Service (VVCS) are paying for sessions

SIRA - NSW Workers Compensation Insurance

Other insurer paying - eg CTP Insurance or MVA related

No Rebate will be claimed (and we can email you an invoice)

Private Health Insurer Name (Eg BUPA, Medibank or HCF)*

Private Health Membership Number*

Client Medicare Card number (10 digit number)*

NUMBER in front of client's name on the MEDICARE CARD (eg 1, 3)*

Address REGISTERED WITH Medicare*

AddressSuburbPostcode

Full Name of the Adult that the Medicare rebate needs to be paid to (the Claimant)*

Date of Birth (DOB) of the Adult Claimant that the Medicare rebate needs to be paid to (the Claimant)*

Is the Adult Claimant's Medicare card number (10 digits on the Medicare card) the same as the child client above

Yes - the Adult claimant's Medicare card number is the same as the child client's

No - the Adult claimant has a different Medicare card number (please type it in the box below)

The Medicare card number (10 digits) of the Adult claimant*

What is the number in front of the Adult Claimant's name on the Medicare card (eg 1, 2 or 3 usually)*

Is your BANK ACCOUNT registered with Medicare (rebates go back to this card, NOT back onto the card you paid with)*

YES - Medicare Rebates will be paid into this account

NO/UNSURE - You will need to contact Medicare to register your bank account either Before or After your first session

If you have a Mental Health Treatment Plan (MHP) or referral from your GP or Psychiatrist already, we need you to enter some information from it below to be able to process your rebate faster. Or leave the following boxes blank if you to not have a copy of your MHP or referral with you now. IMPORTANT - when you get the MHP you need to take a picture of your MHP or referral on your phone/scan it and email it to us (taking it to the session will result in rebates taking longer to process)

Your referring GP's (or Psychiatrist's) first and last names (if you have this information with you now)

Your referring GP's (or Psychiatrist's) Medicare provider number (it is on your Mental Health Plan or referral, as is 7 numbers + 1 Letter, eg 3485687T, if you have this information with you now)

The date on the Mental Health Plan or Referral (eg 12.01.18)

Department of Veterans Affairs (DVA) Card Number:

What type of DVA card do you have:

Gold Card

White Card

Orange Card

What is your DVA card number:

Vietnam Veterans Counselling Service (VVCS) number:

What date is your first session with Claire (Eg 02.06.18)

Terms and Conditions and Consent

1. Dr Claire Godsell is your "treating psychologist" responsible for your care, you are "the client" (yourself or the child or adolescent you are organising services for), and Changes Psychology is the admin and billing service "provider" that is only responsible for processing clients' bookings, billing and client administration only. By signing this agreement you are agreeing to the provision of services under this arrangement

2. Privacy - We work like a virtual clinic office, collecting and managing personal and medical information provided by you and your psychologist, which naturally includes sensitive health information. For more about privacy, and who to contact if you have questions regarding privacy, see our Privacy Policy

3. Medicare clients - For clients who have been referred by a GP, Psychiatrist or Paediatrician, Claire is required by Medicare to write a letter back to the referring doctor detailing your assessment, treatment and progress after the completion of a block of sessions approved by your Mental Health Treatment Plan or referral. If you are granted further sessions following review of your treatment plan, continued written feedback by Claire to your referring doctor will be required by Medicare, following each block of sessions granted

4. Session fees for 2018 = $200 per session of approximately 50 minutes. Also note that there may be session fee increases to cover increased practice costs

5. Confirming your first appointment booking - when you make or made your first booking with a receptionist, they will take and store your credit or debit card details in our Health Kit Practice Management software to confirm the booking. By providing these details and signing this agreement you are consenting to the storage of your card details occurring. No money will be deducted from this card, unless you cancel within 24 hours of your scheduled session or do not show for a booked session time (when the cancellation fees listed below will apply).

6. Cancellation Policy: You are requested to give at least 24-hour’s notice if you need to cancel or postpone any appointment, otherwise you will be charged the full session fee (except in extenuating circumstances). The fee will be deducted from your stored credit card before further sessions can be booked.

7. Session fees will be payable to Claire via Eftpos terminal or cash at the end of every appointment. However any cancellation fees charges, or session payments not made on the day, will be deducted from your stored credit or debit card

To agree to these policies SIGN IN THIS BOX with your finger (on mobile device) or use your mouse*